=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447064845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NICHOLES HEALTH AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2025
-----------------------------------------------------
Last Update Date | 02/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 ERWAY CT
-----------------------------------------------------
City | KINGSPORT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37664-5176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-856-2741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 317 ERWAY CT
-----------------------------------------------------
City | KINGSPORT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37664-5176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-856-2741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NICHOLE LEATHERWOOD
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 423-856-2741
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------